Out of the Shadows: Mental Health in Asia Pacific

Mental health has been a peripheral issue in emerging markets for a long time, despite the severe impact not only on those directly affected but also on families and carers, as well as on social cohesion and economic development.

Fortunately, mental health is starting to get more attention but there is still a widespread tendency to stigmatize and discriminate against people suffering with a mental illness. They are often considered as dangerous and aggressive which in turn increases the social distance.

Is there an opportunity for pharma to do more? In the first of a series of articles exploring mental health in emerging markets we take an in-depth look at the situation in Asia where problems arising from ill mental health are the second largest contributor to years lost to disability.

Across Asia-Pacific, anything from 4% (Singapore) to 20% (Vietnam, Thailand, New Zealand, Australia) of the adult population experiences a diagnosable mental illness in any given year. There are indications too that in some countries – such as China, India, Japan, Korea, Thailand and Malaysia – prevalence rates have increased. A study in The Lancet found that mental, neurological and substance-use disorders, which accounted for 7% of disability-adjusted life years across China in 1990, had risen to 11% by 2013. In India, the burden of disease increased from 3% in 1990 to 6% in 2013.

Economic damage
Data from the World Health Organization (WHO) and the Organization for Economic Cooperation and Development identify the five leading mental health problems in the region as depression, anxiety, post-traumatic stress disorder, suicidal behavior and substance-abuse disorder. A cross-sectional study on major depressive disorder, for example, showed a prevalence of 20.0% in Thailand, 19.9% in Taiwan, 19.4% in Korea, 17.5% in Malaysia and 16.5% in China.

Few of these conditions are adequately addressed in many Asia-Pacific countries, although, in the last few years, there has been concerted efforts in Asia-Pacific countries to raise the profile of mental health, establish legal and policy frameworks for more comprehensive, coordinated disease management, expand investment in infrastructure and human resources, and reduce stigmatization. Partly this acknowledges the heavy economic toll exacted by mental illness; without factoring in suicide, mental health issues are projected to reduce economic growth in both India and China by more than $9 trillion respectively between 2016 and 2030.

Huge regional variation
A common goal underlying these efforts is de-institutionalization; changing the focus of mental health management from secondary care – often overcrowded, understaffed and, at worst, marked by human-rights abuses – to integrated community-based care with multidisciplinary input.

Inevitably, given the huge variance in demographics, economic development and cultural attitudes across the region, some countries are much further along this path than others. At one extreme, more developed economies such as Australia and New Zealand have devoted considerable resources to build frameworks for joined-up mental healthcare at community level (even if there is work to do on reaching socially marginalized and rural communities). At the other end of the spectrum are lower middle-income countries such as India, the Philippines, Vietnam, Indonesia, and Pakistan. Here, there are many challenges, including little available medical treatment, inadequate investment (typically only 1% or less of meagre healthcare budgets), lack of capacity to spend funds effectively, dilapidated facilities, and critically low numbers of mental health professionals. In India, Pakistan and Indonesia, for example, there are 0.3 or fewer psychiatrists per 100,000 population.

Filling the gaps

Even in middle-income countries that have made significant progress in tackling mental health issues, such as China and Thailand, many problems remain. In China, there are approximately 20,000 psychiatrists for a population of 1.4 billion; around 92% of an estimated 173 million people in China suffering from mental disorders go without care. This treatment gap reflects historical neglect of mental illness, inadequate funding, stigmatization, low numbers of qualified personnel, poor access to treatment and facilities (particularly in rural areas), and limited coverage for mental health issues under medical insurance. In these circumstances, responsibility for managing mental illness often falls to family members; with schizophrenics in rural China, 52% of primary caregivers interviewed rated their family burden as moderate to severe, with financial difficulties (76%) the most common concern.

Whereas international models of mental health prioritize the individual, more family-oriented cultures in Asia-Pacific countries may complicate moves to expand community-based services and access to professional care, especially if lack of funding obliges families to accommodate patients. Internal conflicts can lead to families rejecting discharged patients, returning them to institutions or even shackling them in outhouses. In one study of Chinese families who had restrained family members with severe mental illness in their homes, 96% of relatives cited financial problems and 87% serious difficulties finding capable caregivers.

Stigmatization persists
Even high-income countries with relatively advanced healthcare systems, such as Japan, South Korea and Hong Kong, continue to lag significantly in areas such as funding, mental health workforce or breaking the cycle of institutionalized care. There are also lingering problems across the region, such as sharp rural-urban divides in access to mental health services.

Stigmatization, including negative attitudes towards families caring for the mentally ill, persists in many countries, particularly where conformity and fear of losing face are paramount. This may manifest as belief that the mentally ill are possessed, dangerous, contagious or morally deficient. They may be socially excluded, hindering efforts to form long-term relationships or find stable employment. Self-stigmatization can exacerbate these problems through avoidance of diagnosis and treatment. Even in a relatively westernized country such as Singapore, a recent study found that half of the population regarded mental illness as a “sign of personal weakness”, while nine in 10 felt that those affected “could get better if they wanted to”.

Unmet need
For the pharmaceutical industry, unmet need creates significant opportunities. According to one estimate, Asia-Pacific is the third largest market for mental health therapeutics worldwide, behind North America and Europe but expected to grow at the fastest annual rate between 2017 and 2025.

In countries piecing together an infrastructure for community-based mental healthcare, the availability of pharmacological therapies may be characterized by under-supply on limited budgets, or oversupply as hard-pressed practitioners substitute quick fixes for considered diagnosis and treatment.

Neither of these scenarios is in the long-term interests of pharmaceutical companies that want to see biomedical intervention incorporated into a broader, multilayered approach to mental health management. So, what can these companies do to help bring mental health out of the shadows? Outcomes data could be especially beneficial; lack of data on mental health trends have frustrated attempts to drive policy changes and improve the quality of care in many Asia-Pacific countries.

Pharmaceutical companies can also support educational initiatives aimed at better integrating services into the community and encouraging acceptance of mental health conditions as manageable diseases. This is one goal of Janssen’s Healthy Minds program for the Asia Pacific region. A range of collaborations and public-private partnerships includes support for more than 1,000 lectures across China to raise awareness of mental illness, co-production of a full-length film in the Philippines about living with schizophrenia, and a public-awareness campaign aimed at changing perceptions of schizophrenia in Indonesia.

Companies can support much-needed human resources, such as specialist mental health nurses or training community workers to recognize and manage mental-health problems. Drawing on their experience of tracking care pathways worldwide, they can argue for system change that reduces insurance exclusions or ensures appropriate pricing and reimbursement of medicines with potential to reduce institutionalization and optimize limited healthcare capacity.

Beyond the pill
At the same time, companies need to avoid accusations that they are only interested in medicalizing previously marginal conditions. This is where ‘beyond-the pill’ strategies geared to education, understanding and support for patients and carers can be particularly useful. Apps, online programs and other mobile-health initiatives may boost patient engagement and health literacy, particularly in countries such as China, Indonesia, Malaysia or the Philippines, where there is variable access to mental-health services.

According to Frost and Sullivan, the Asia-Pacific market for chronic disease management platforms in home health monitoring could grow at a compound annual rate of 12.8% between 2015 and 2020. Nonetheless, issues such as reliability, standardization, (cost-) effectiveness, compliance and data security must be addressed if digital technologies are to become core to mental-health management.

Companies must also remain sensitive to cultural difference and the preference in some countries for supra-medical resources such as faith healers, traditional therapies or meditation. These should be treated as complementary strategies that can aid patient commitment and therapy adherence.

Much has been achieved in recognizing mental illness and laying the foundations for humane, effective care in the Asia-Pacific region. China’s Program 686 for psychosis management, for example, started with 60 demonstration sites in 2005. By the end of 2014 it had rolled out to 87% of administrative districts, providing community-based management and services for 3.15 million people with serious mental illnesses.

But raising the profile of mental health also exposes significant gaps in current provision. The pharmaceutical industry can help to fill these by taking a 360˚-health approach to mental health in Asia-Pacific countries, echoing the WHO’s rallying cry of “no health without mental health”. That will position medicines and associated services as essential drivers in the shift towards patient-centered, integrated mental healthcare.

Marc Yates is Director of Emerging Markets at Research Partnership. Next month, Marc will be discussing mental health in Latin America.

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